Global Health: A New Age in Worldwide Partnerships

When reports of the H1N1 influenza outbreak started hitting the news earlier this year, much of the discussion centered on how to contain the disease. Some people assumed that limiting travel or closing borders would prevent the spread of this new, potentially deadly, strain of influenza.

But anyone who has worked in public health knew this wasn’t possible. We are living in a world where infectious diseases spread around the world in a matter of hours.

Perhaps the biggest lesson of the H1N1 outbreak is that we are truly living in an era of global health. Where we live is becoming less important than how we live. More than infectious agents, chronic conditions such as obesity, cardiovascular disease, and certain types of cancer, once limited to affluent countries, are now circling the globe to developing countries.

The University of Minnesota School of Public Health is built on the tenet that public health is global health. Some of the school’s earliest researchers helped to pioneer this philosophy. In the early 1960s, the University’s own Ancel Keys traveled to Europe, Africa, and Asia to systematically study the diets and customs of different cultures.

SPH professor emeritus Henry Blackburn worked with Keys on the project, known as the Seven Countries Study, one of the first global research initiatives to link lifestyle and diet to health.

Today the work of SPH faculty is conducted on five continents and in more than a hundred countries. While challenges such as HIV prevention, pandemic planning, tobacco control, and food safety are immense, so are the opportunities.

Technological advances have paved the way, but so has a worldwide desire to collaborate on the health issues that affect us all. Never before has the school partnered so extensively with researchers and educators throughout the world.

Tobacco Control

While America has seen progress in cutting smoking rates, tobacco use remains the single largest preventable cause of disease and premature death in the world. The World Health Organization estimates that of the world’s 1.22 billion smokers, 1 billion live in developing or transitional economies. If left unchecked, deaths from tobacco use are expected to double by 2030.

Tobacco control in the developing world was the focus of the 14th World Congress on Tobacco or Health held earlier this year in Mumbai, India. Originally scheduled to be held in Geneva, Switzerland, some involved felt that a conference focusing on smoking in the developing world should be held in the developing world.

Leading that charge was SPH Distinguished International Professor Harry Lando, an expert on global approaches to tobacco reduction.

As vice president of the conference, Lando played a lead role organizing the event and raising financial support. Sponsors included the Bill and Melinda Gates Foundation, World Heart Foundation, Pfizer, and the SPH. Attendance exceeded expectations with some 2,000 people from more than 130 counties. Speakers included the heath minister of India and the director general of the World Health Organization. SPH alumna Hitakshi Sehgal (M.P.H. ’08), who lives in India, worked with Lando on conference planning.

“This conference was key in setting a unified and global agenda on tobacco control,” says SPH dean and attendee John Finnegan. “Harry’s leadership was critical in pulling together the network that made this event a success.”

Lando says he is pleased that the World Congress is starting to have an impact on countries with the greatest tobacco burden. He notes that more than 60 percent of the conference delegation represented countries of middle to low incomes.

“This is a first for us,” he says. “But we have so much more to do.”

Lando and colleagues are working to cut the projected death toll from tobacco¿estimated to be in the billions¿by at least 10 percent.

“Imagine the impact, the lives saved,” says Lando. “The goal is, really, to change the world.”

Global Learning

The school is globally engaged in the pursuit of educating the next generation of public health leaders. Over the past five years, the SPH has forged partnerships with colleagues in India to help build the country’s nascent public health infrastructure and develop a healthy workforce.

Those partnerships helped pave the way for Global Health India, a collaboration of the SPH, St. John’s Medical College in Bangalore, and several other colleges in India. The fiveday institute, held on St. John’s campus, offered courses examining the impact of globalization and strategies for a healthy workforce. Nearly a dozen University of Minnesota students, mostly from the SPH, attended. They learned alongside some 160 Indian students.

Half a dozen SPH faculty members taught courses, as did instructors from Indian institutions. University of Minnesota faculty members from nursing, dentistry, medicine, and veterinary medicine also taught.

Topics included infectious diseases, genomics, climate change, nutrition, children’s health, and health management. Students and instructors discussed strategies for developing international partnerships to create globally minded public health interventions.

“Public health issues transcend national borders,” says SPH professor William Toscano, an institute instructor. “If we are to effectively address these issues, we need to do so from a global perspective.

HIV Prevention

For more than 20 years, SPH professor Alan Lifson has traveled throughout the world to improve care for those with HIV. This work has taken him to Asia, Eastern Europe, Latin America, the Caribbean, and Africa. Ethiopia is the sixth African country he has worked with, and it is the site of one of his current projects.

Ethiopia, like other African countries, has some of the world’s highest HIV rates and some of the most limited resources to deal with the immense challenge. Treatment of the disease requires lifelong therapy. It can be complicated, costly, and associated with side effects. Many patients stop taking medication or are lost in follow-up.

Lifson’s team is conducting an evaluation to identify the reasons patients are lost in the health system or stop HIV treatment. Once those reasons are identified, the team will create interventions to improve retention. Partnering organizations include the National Alliance for State and Territorial AIDS Directors and the World Health Organization, with support from the Centers for Disease Control and Prevention.

“We’re finding that rural areas face a unique set of barriers,” says Lifson. For instance, those in remote villages may not have access to reliable transportation or a nearby clinic. This is a case where HIV care must be available at local health clinics, and where community health workers may be called upon to act as a bridge between clinics and the villages where patients live.

The evaluation is comprehensive, taking on a wide scope of potential barriers to treatment, such as availability of family and community support, distance to and accessibility of clinics, social stigma, drug side effects, nutrition, and lack of patient education.

“We want to make sure the assessment is quickly translated to interventions,” says Lifson. “The goal is to use scientific methods to create the best available care to improve the health of HIV-infected persons.”

Environmental Health

SPH assistant professor Paul Allwood is working with health officials in Jamaica on a range of initiatives aimed at protecting the public from environmental hazards.

The Jamaican Ministry of Health enlisted Allwood to research the causes of leptospirosis, a potentially harmful infectious disease that is endemic to tropical climates. In 2005, a leptospirosis outbreak caused hundreds of cases of illness and death among Jamaican adults and children.

While it is known that domestic animals, especially dogs, play a large role in the transmission, there has been little scientific surveillance of the disease in Jamaica.

Allwood is working to change that through a series of field visits, surveys, and geographically referenced data. The information will be used to predict future outbreaks and as a basis for community-based interventions to prevent transmissions. Preliminary data is beginning to come in now, and the team expects to have recommendations within the next six months.

The Ministry of Health in Jamaica, along with the University of the West Indies, is working with Allwood to plan research and interventions aimed at curbing violence among Jamaican youth. The government has identified violence as a priority area in its healthy youth initiative.

Outside of the research arena, Allwood is working to promote partnerships between faculty of the SPH and the University of the West Indies. For several years, he has been involved in planning an annual conference that draws participants from the United States and the Caribbean. Presenters at the last conference included SPH dean John Finnegan, who discussed the use of scientific evidence in the policymaking process.

Influenza Surveillance

The recent H1N1 influenza outbreak confirms the need to ramp up worldwide surveillance so that disease can be limited in its most early stages. This is especially true in developing countries with limited resources and large human and animal populations. A team from the Minnesota Center of Excellence for Influenza Research and Surveillance (MCEIRS) recently met with colleagues in India to enhance regional influenza surveillance.

India is just one country in the global network forged by MCEIRS since it launched two years ago. Funded by the National Institutes of Health, the center’s goal is to enhance understanding of how avian influenza viruses evolve, adapt, and spread. MCEIRS is part of the University of Minnesota’s Center for Infectious Disease Research and Policy (CIDRAP).

Discussions with Indian officials were led by SPH professor and MCEIRS director Michael Osterholm. Wildlife refuges were identified as a starting point for surveillance of India’s vast population of wild migratory birds. Surveillance near the flyways will be conducted in backyard farms, live poultry markets, and processing facilities.

Plans include training local workers to collect samples from birds, conduct laboratory diagnostics, and sequence viral genomes. The group proposed U.S. and India academic and professional exchanges to share surveillance techniques.

“One major lesson from the H1N1 outbreak is that we need to make our recommendations for reducing transmission relative to the severity of the disease,” says Osterholm, citing unnecessary school closing as an example. “Ramping up worldwide surveillance is key to improving disease response.”

Food Safety

The Centers for Disease Control and Prevention estimates that 75 percent of the food we eat has at least one ingredient grown, processed, packaged, and shipped from another country. As our food supply continues to become more globally sourced, ensuring the safety of what we eat and drink becomes more challenging.

Since launching in 2007, the Global Initiative for Food Systems Leadership (GIFSL) has provided educational opportunities to emerging leaders from 35 countries. GIFSL fosters experiential education through a global network of universities, intergovernmental agencies, and private industry. Partnering organizations include the World Health Organization, the Food and Agriculture Organization of the United Nations, Cargill, and General Mills.

GIFSL executive director Will Hueston, a professor in the SPH and College of Veterinary Medicine, is an internationally known expert on global food systems. SPH professor Craig Hedberg also serves on GIFSL.

In the past year, GIFSL has led a “farm-to-table” study tour in the Netherlands, lectures for students at the University of Iceland, and an international working group on leadership involving government, industry, and non-profit organizations. Under the guidance of GIFSL, 19 senior Chinese officials spent two weeks gathering food safety strategies in Europe and the United States. The tour included stops in Italy, Belgium, the Netherlands, Washington, D.C., and Minnesota.

“The premise was that food safety is a shared responsibility between the public and private sectors, academia, and consumers,” says Hueston, who led the program. “The idea was to introduce some universally accepted international standards for safe food production and trade.”

Next up for GIFSL is a farm-to-table study tour of Uruguay and Argentina. The group plans to visit a dairy processor and beef plant, tour a cattle farm, and meet with faculty and students from the Universidad de la Republica veterinary school in Uruguay.